Ultrasound imaging in pediatric regional anesthesia

[Effects of caudal block in pediatric surgical patients: a randomized clinical trial]

BACKGROUND

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

OBJECTIVES

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

METHODS

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

RESULTS

Children who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

CONCLUSIONS

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Effects of caudal block in pediatric surgical patients: a randomized clinical trial

Background

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

Objectives

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

Methods

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

Results

Children who received a caudal block had significantly lower serum glucose (p <  0.01), cortisol concentrations (p <  0.01) and pain scores 3 h (p =  0.002) and 6 h (p =  0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

Conclusions

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Applications of regional anaesthesia in paediatrics

Advances in the field of paediatric regional anaesthesia have specific applications to both acute and chronic pain management. This review summarizes data regarding the safety of paediatric regional anaesthetic techniques. Current guidelines are provided for performing paediatric regional techniques, with a focus on applications for postoperative pain management. Brief descriptions of relevant anatomy followed by indications for commonly performed blocks are highlighted along with the potential of adverse side-effects.

Ultrasound-guided proximal and distal sciatic nerve blocks in children

STUDY OBJECTIVE

To present the use of ultrasonography for the performance of proximal subgluteal and distal sciatic nerve blocks in children.

DESIGN

Prospective descriptive study.

SETTING

University hospital.

PATIENTS

45 ASA physical status I, II, and III patients, aged between 8 months and 16 years, scheduled for lower limb surgery.

INTERVENTIONS

During general anesthesia, proximal, subgluteal, and distal sciatic nerve blocks using ultrasonography were performed. If severe postoperative pain was expected, a catheter technique was used.

MEASUREMENTS

The injected amount of local anesthetic was noted. Based on the spread of local anesthetic, prediction for successful block was made. Complications, adverse effects, postoperative pain scores, and parent satisfaction scores were noted.

MAIN RESULTS

21 proximal sciatic nerve blocks (12 single-injection and 9 continuous blocks) and 35 distal sciatic nerve blocks (17 single-injection, 6 bilateral single-injection, 4 continuous, and one bilateral continuous block) were performed. A mean initial dose of 0.25 mL.kg(-1) of ropivacaine 0.375% was injected. A successful block was obtained in all children. Excellent postoperative pain relief was obtained. All parents were satisfied with the postoperative pain relief. No complications occurred.

CONCLUSION

Ultrasonography is useful in the identification of the sciatic nerve and it facilitates needle and catheter placement for proximal and distal nerve blocks in children.

Ultrasound in regional anaesthesia

Ultrasound guidance is rapidly becoming the gold standard for regional anaesthesia. There is an ever growing weight of evidence, matched with improving technology, to show that the use of ultrasound has significant benefits over conventional techniques, such as nerve stimulation and loss of resistance. The improved safety and efficacy that ultrasound brings to regional anaesthesia will help promote its use and realise the benefits that regional anaesthesia has over general anaesthesia, such as decreased morbidity and mortality, superior postoperative analgesia, cost-effectiveness, decreased postoperative complications and an improved postoperative course. In this review we consider the evidence behind the improved safety and efficacy of ultrasound-guided regional anaesthesia, before discussing its use in pain medicine, paediatrics and in the facilitation of neuraxial blockade. The Achilles' heel of ultrasound-guided regional anaesthesia is that anaesthetists are far more familiar with providing general anaesthesia, which in most cases requires skills that are achieved faster and more reliably. To this ends we go on to provide practical advice on ultrasound-guided techniques and the introduction of ultrasound into a department.

A survey of pediatric caudal extradural anesthesia practice

BACKGROUND

Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice.

OBJECTIVES

To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia.

METHODS

An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008.

RESULTS

There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection.

CONCLUSIONS

This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.

Ultrasound imaging techniques for regional blocks in intensive care patients

Ultrasound imaging techniques have gained great popularity in anesthesia during the last decade. They have been shown to allow better quality of regional blocks, improving the outcome of patients and reducing the costs at the same time, for two major reasons. First, ultrasound imaging provides information of the individual anatomic structure and abnormalities before puncture. Second, the ultrasound-guided puncture is displayed in real time, and this enables the physician to correct the direction of the needle, both to improve the spread of local anesthetics and to avoid tissue damage. Ultrasound imaging allows control, even in difficult cases and in situations with variations of normal anatomy. Even positioning dependent variations of nerve roots can be managed most effectively. In addition, the time can be reduced considerably to perform regional blocks; the onset time is shorter, and the quality of blocks is better. So, ultrasound imaging techniques are routinely applied in the University Clinics Bergmannsheil, Bochum, Germany.

Ultrasonography in the current practice of regional anaesthesia

Ultrasound imaging techniques in regional anaesthesia are becoming a subject of major interest. The quality of blocks and analgesia is relevant to the perioperative outcome of patients and the development of perfect blocks has always been a focus in regional anaesthesia research. Several studies in neuroaxial anaesthesia and peripheral blocks have found that puncture processing performed under ultrasound guidance is easier and more effective than that performed without such guidance, thus ultrasound imaging techniques are being developed for clinical practice. One of the major advantages of these techniques is that they provide the opportunity to show the patient the anatomical situation before the puncture--using a near harmless and effective technique. A second advantage is that the puncture process and the application of medication can be demonstrated and clearly observed during the performance. If there is a problem with the spread or the application, the processing of the block can be immediately modified to improve the quality of the technique.